Provider Demographics
NPI:1972940401
Name:BANNON, CARL JAY
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:JAY
Last Name:BANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 JACQUELINE AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743-5716
Mailing Address - Country:US
Mailing Address - Phone:603-542-4831
Mailing Address - Fax:
Practice Address - Street 1:71 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743
Practice Address - Country:US
Practice Address - Phone:603-543-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist